cmecde 5456

 

Cardiovascular and respiratory medicine

Station 12 Blood pressure measurement 27

Examiner’s questions

Causes of secondary hypertension:

• Endocrine causes:

– high catecholamines, e.g.

phaeochromocytoma

– high glucocorticoids, e.g. Cushing’s

syndrome

– high mineralocorticoids, e.g. Conn’s

syndrome

– high growth hormone, e.g. acromegaly

– hyper- or hypo-thyroidism

– hyperparathyroidism

• Renal disease

• Vascular causes:

– renal artery stenosis

– coarctation of the aorta

• Pregnancy:

– gestational hypertension

– pre-eclampsia (+ oedema and proteinuria)

• Drugs:

– NSAIDs, steroids, oestrogen, illicit drugs

Complications of hypertension:

• Cerebrovascular accident (haemorrhage or

ischaemic infarct).

• Retinopathy.

• Ischaemic heart disease.

• Left ventricular failure.

• Renal failure.

• Atherosclerosis.

• Aneurysm.

Investigations in hypertension:

• Confirming hypertension.

• Assessing for a possible secondary cause.

• Assessing for complications/end-organ

damage (see above) e.g. fundoscopy, ECG,

blood tests such as urea and electrolytes.

Artery

Stethoscope

Sphygmomanometer

Right arm

Cu�

Figure 5. Positioning of the cuff and head

of the stethoscope.

Clinical Skills for OSCEs

28 Station 13

Cardiovascular examination

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• Position him at 45 degrees, and ask him to remove his top(s).

• Ensure that he is comfortable.

• Wash your hands.

The examination (IPPA)

General inspection

• From the end of the couch, observe the patient’s general appearance (age, state of health,

nutritional status, and any other obvious signs). Is he breathless or cyanosed? Is he coughing?

Does he have the malar flush of mitral stenosis?

• Observe the patient’s surroundings, looking in particular for items such as a nitrate spray, an

oxygen mask, ECG electrodes, and IV lines and infusions.

• Inspect the chest for any scars and the precordium for any abnormal pulsation. A median

sternotomy scar could indicate coronary artery bypass grafting (CABG), valve repair or replacement, or the repair of a congenital defect. A left submammary scar most likely indicates repair

or replacement of the mitral valve. Do not miss a pacemaker if it is there!

Inspection and examination of the hands

• Take both hands noting:

– temperature: feel with the back of your hand

– colour, in particular the blue of peripheral cyanosis and the orange of nicotine stains

– nail bed capillary refill time: press the nail for 5 seconds; it should refill within 2 seconds

– any presence of clubbing (endocarditis, cyanotic congenital heart disease)

– any presence of Osler nodes and Janeway lesions (subacute infective endocarditis)

– any presence of splinter haemorrhages (subacute infective endocarditis)

– any presence of koilonychia or ‘spoon nails’ (iron deficiency)

• Determine the rate, rhythm, volume, and character of the radial pulse. A regularly irregular

rhythm suggests second degree heart block, whereas an irregularly irregular rhythm suggests

atrial fibrillation or multiple ectopics.

• Raise the patient’s arm above his head to assess for a collapsing/water hammer pulse (aortic

regurgitation). Ask the patient whether he has any shoulder pain first.

• Simultaneously take the pulse in both armsto exclude radio-radial delay (aortic arch aneurysm).

Indicate that you would also exclude radio-femoral delay (coarctation of the aorta).

• As you move up the arm, look for bruising, which may indicate that the patient is on an anticoagulant, and for evidence of intravenous drug use, which is a risk factor for acute infective

endocarditis.

• Indicate that you would like to record the blood pressure (see Station 12). A wide pulse pressure

is typically seen in aortic regurgitation; a narrow pulse pressure in aortic stenosis.

Cardiovascular and respiratory medicine

Station 13 Cardiovascular examination 29

Inspection and examination of the head and neck

• Inspect the eyes, looking for peri-orbital xanthelasma and corneal arcus, both of which indicate

hyperlipidaemia.

• Gently retract an eyelid and ask the patient to look up. Inspect the conjunctivusfor pallor, which

is indicative of anaemia.

• Ask the patient to open his mouth, and look for signs of central cyanosis, dehydration, poor

dental hygiene (subacute bacterial endocarditis), and a high arched palate (Marfan’ssyndrome).

• Palpate the carotid artery and assess its volume and character. A slow-rising pulse is suggestive

of aortic stenosis, a collapsing pulse of aortic regurgitation. Never palpate both carotid arteries

simultaneously.

• Assess the jugular venous pressure (see Figure 6) and, if possible, the jugular venous pulse form:

ask the patient to turn his head slightly to one side, and look at the internal vein medial to the

clavicular head of sternocleidomastoid. Assuming that the patient is reclining at 45 degrees,

the vertical height of the jugular distension from the angle of Louis (sternal angle) should be

no greater than 4 cm: if it is greater than 4cm, this suggests right heart failure, fluid overload,

or tricuspid valve disease.

Palpation of the heart

Ask the patient if he has any chest pain.

• Determine the location and character of the apex beat. It is normally located in the fifth intercostal space at the midclavicular line. The apex may be:

– impalpable: obesity, dextrocardia, situs inversus…

– displaced, suggesting volume overload (mitral or aortic regurgitation)

– heaving, suggesting pressure overload and left ventricular hypertrophy (aortic stenosis)

– ‘tapping’, suggesting mitral stenosis

• Place the flat of your hands over either side of the sternum and feel for any heaves and thrills.

Heaves result from right ventricular hypertrophy (cor pulmonale) and thrills from transmitted

murmurs.

45°

Height of jugular

venous distention

Angle of Louis

(sternal angle)

4 cm

Figure 6. Assessing

the jugular venous

pressure.

Clinical Skills for OSCEs

30 Station 13 Cardiovascular examination

Auscultation of the heart

• Listen for heart sounds, additional sounds, murmurs, and pericardial rub. Using the stethoscope’s diaphragm, listen in the:

– aortic area

right second intercostal space near the sternum

– pulmonary area

left second intercostal space near the sternum

– tricuspid area

left third, fourth, and fifth intercostal spaces near the sternum

– mitral area (use the stethoscope’s bell)

left fifth intercostal space in the mid-clavicular line

• Manoeuvres and points to remember:

– ask the patient to bend forward and to hold his breath at end-expiration. Using the stethoscope’s diaphragm, listen at the left sternal edge in the fourth intercostal space for the middiastolic murmur of aortic regurgitation

– ask the patient to turn onto his left side and to hold his breath at end-expiration. Using the

stethoscope’s bell, listen in the mitral area for the mid-diastolic murmur of mitral stenosis

– listen over the carotid arteries for any bruits and the radiation of the murmur of aortic

stenosis

– listen in the left axilla for the radiation of the murmur of mitral regurgitation

For any murmur, determine its location and radiation, and its duration (early, mid, late, ‘pan’ or

throughout) and timing (diastolic, systolic) in relation to the cardiac cycle. This is best done by

palpating the carotid or brachial artery to determine the start of systole. Grade the murmur on a scale

of I to VI according to itsintensity (see Table 4). Common conditions associated with murmurs are listed

in Table 5.

A P

T

M

Mid-clavicular

line

Auscultation points

C C

Ax

Figure 7. Auscultation points.

Cardiovascular and respiratory medicine

Station 13 Cardiovascular examination 31

Table 4. Grading murmurs

I Barely audible murmur

II Soft and localised murmur

III Murmur of moderate intensity that is immediately audible

IV Murmur of loud intensity with a palpable thrill

V As above, murmur audible with only stethoscope rim on chest wall

VI As above, murmur audible even as stethoscope is lifted from chest wall

Table 5. Common conditions associated with murmurs

Aortic stenosis Slow-rising pulse, heaving cardiac apex, ejection/early-systolic murmur best

heard in the aortic area and radiating to the carotids and cardiac apex

Mitral regurgitation Displaced thrusting cardiac apex, pan-systolic murmur best heard in the

mitral area and radiating to the axilla, patient may be in atrial fibrillation

Aortic regurgitation Collapsing pulse, thrusting cardiac apex, diastolic murmur best heard at the

lower left sternal edge

Mitral valve prolapse Mid-systolic click, late-systolic murmur best heard in the mitral area

RILE: Right-sided murmurs are heard loudest on Inspiration whereas Left-sided murmurs are heard

loudest on Expiration

Chest examination

• Percuss and auscultate the chest, especially at the bases of the lungs. Heart failure can cause

pulmonary oedema and pleural effusions.

Abdominal examination

• Palpate the abdomen to exclude ascites and/or hepatomegaly.

• Check for the presence of an aortic aneurysm.

• Ballot the kidneys and listen for any renal artery bruits.

Examination of the ankles and legs

• Inspect the legs for scars that might be indicative of vein harvesting for a CABG.

• Palpate for the ‘pitting’ oedema of cardiac failure: check for pain and then press for 5 seconds

on the patient’s legs. If oedema is present, assess how far it extends. In some cases, it may

extend all the way up to the sacrum or even the torso (‘anasarca’).

• Assess the temperature of the feet, and check the posterior tibial and dorsalis pedis pulses in

both feet.

Clinical Skills for OSCEs

32 Station 13 Cardiovascular examination

After the examination

• Indicate that you would look at the observation chart, dipstick the urine, examine the retina

with an ophthalmoscope (for hypertensive changes and the Roth’s spots of subacute infective

endocarditis), and, if appropriate, order some key investigations, e.g. FBC, ECG, CXR, echocardiogram.

• Cover the patient up and ensure that he is comfortable.

• Thank the patient.

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in a cardiovascular examination station

• Murmurs (see Table 5).

• Heart failure.

• Median sternotomy scar, with or without scar on the lower leg (vein harvesting).

• Pacemaker.